§ 1181.83. Inspections of care.
(a) Inspection team. The Department’s Inspection of Care team will inspect the care and services provided to each recipient in a participating nursing facility at least annually. The Department will not give the facility more than 48 hours notice of the time and date of the scheduled arrival of the team. The facility shall make readily available to the team the patient’s complete medical records for the year since the last review of the team. The team’s inspection will include:
(1) Personal contact with and observation of each recipient in a skilled nursing facility, intermediate care facility, or intermediate care facility for the mentally retarded.
(2) Review of each recipient’s medical record. The record must include timely certification and recertifications by the physician that the services are needed and a written individual plan of care developed either by an interdisciplinary team or the attending or staff physician, whichever is applicable. The plan of care must indicate time limits and measurable care objectives and goals to be accomplished and who is to give each element of care.
(b) Determination of inspection. The team will determine in its inspection whether:
(1) The services are available and adequate to meet the recipient’s health needs.
(2) It is medically necessary and desirable for the recipient to remain in the facility.
(3) Recipients receiving skilled care meet the minimum medical requirements for skilled nursing care specified in § 1181.53(b)(2) (relating to payment conditions related to the recipient’s initial need for care).
(4) It is feasible for the facility to meet the recipient’s health needs and, in an ICF, the recipient’s rehabilitative needs or whether the recipient’s needs could be met through alternative institutional or noninstitutional services.
(5) Each recipient in an intermediate care facility for the mentally retarded is receiving active treatment.
(6) The medical evaluation including any required psychological or social evaluations and the plan of care are complete and current, are followed, and all ordered services are provided and recorded.
(7) The recipient receives adequate services based on personal observations, that is, the recipient is clean, bedsores are absent, there is absence of signs of malnutrition or dehydration and there is apparent maintenance of maximum physical, mental and psychosocial function.
(8) In an ICF, there is evidence of a planned activities program to prevent regression and there is progress toward meeting goals of the plan of care.
(9) Service needs are met by the facility or by outside arrangements.
(10) Recipient needs continued placement in the facility or there is an appropriate plan to transfer to an alternate level of care.
(c) Reports on inspections of care.
(1) The Inspection of Care team will develop a summary report at the conclusion of its inspection of each facility. The report will include:
(i) The alternate care determinations.
(ii) Findings of the adequacy and quality of care rendered by the facility. The findings will specify that the care rendered is acceptable or in need of improvement.
(2) Within 45 days following the conclusion of the inspection, two copies of the summary report will be forwarded to the administrator of the facility. The administrator shall forward one copy of the summary report to the Utilization Review Committee chairperson. On the second copy of the summary report, the administrator will give written responses to each area identified as deficient and all narrative recommendations.
(3) In advance of forwarding the summary report to the facility, the Inspection of Care team will notify the County Assistance Office and the facility of any alternate care determinations made by the team.
(d) Recipient right of appeal of alternate care determinations. The recipient or the person or the nursing facility acting on the behalf of the recipient, in accordance with Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings), has 30 days in which to appeal the Inspection of Care team’s alternate care determination. Neither the facility, the facility’s Utilization Review Committee, nor the recipient’s attending physician has the right to appeal the alternate care determination on their own behalf. If the recipient or the person or the facility acting on behalf of the recipient appeals the decision within 10 calendar days from the date the County Assistance Office issues the advance notice, payment for the present level of care will continue pending the outcome of the hearing subject to the provisions of § 1181.54(g) (relating to payment conditions related to the recipient’s continued need for care).
Authority The provisions of this § 1181.83 amended under sections 403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S. § § 403(a) and (b) and 443.1(2) and (3)).
Source The provisions of this § 1181.83 codified July 24, 1981, effective July 25, 1981, 11 Pa.B. 2610; amended January 7, 1983, effective January 8, 1983, 13 Pa.B. 148. Immediately preceding text appears at serial pages (62948) to (62949).
Notes of Decisions DPW Inspection of Care procedural regulations at 55 Pa. Code § 1181.83(b) are in conformance with federal regulations at 42 CFR 456.600—456.614. Fifty Residents of Park Pleasant Nursing Home v. Commonwealth, 503 A.2d 1057 (Pa. Cmwlth. 1986).
Cross References This section cited in 55 Pa. Code Chapter 1181 Appendix O (relating to OBRA sanctions).
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